GARNER -- Editor's note: This fall, The N&O is talking to people about the nation's health care system: what works, what doesn't and what should be done to fix it.

With her diabetes, high blood pressure and cholesterol under control, Gail Johnson expects to be around to see her grandchildren grow up. But the 56-year-old figures she'll die long before she's able to pay off her hospital bills.

"I don't even know how much I owe WakeMed. That's how bad it is," she says, guessing it's well over $20,000.

ohnson amassed that debt doing what uninsured Americans do millions of times each year when they get sick: Go to a hospital emergency room.Emergency rooms have become the U.S. health care system's safety net, where anyone can go for treatment and no one can be turned away because they can't pay in advance.

But experts say using emergency care in place of checkups and doctor visits is the most expensive way to deal with chronic illness. Many of the 119.2 million emergency visits racked up in 2006 were for problems that could have been prevented through regular primary care. More than 17 percent of those visits - nearly 21 million - were made by patients who had no insurance, according to the National Center for Health Statistics.

The average emergency room bill is about $1,300; much more if the patient is admitted. A visit to a doctor's office starts around $75.

But hospitals are required to take patients who have no insurance and no ability to pay; they bill later and hope to collect. Doctors' offices require proof of insurance or payment at the time of service.

Johnson's was a typical case.

During her 27-year marriage, she says, she was insured through her husband's policy at work. When they split up more than a decade ago, she lost her coverage. She found work, but never with benefits.

So she went years without going to a doctor, a dentist or an ophthalmologist. She didn't realize her blood sugar was out of whack, and her blood pressure and cholesterol were rising. The first time she went to the WakeMed emergency room, she had a major kidney infection and severe dehydration.

Emergency physicians got Johnson stabilized and referred her to an endocrinology practice in Raleigh. At about $80 each, office visits cost more than a fourth of Johnson's weekly take-home pay. Johnson filled her prescriptions when she had the money.

But most of the time, medications she was supposed to take daily, she took every other day or every other week to make them last, a practice her doctor later said would tax her kidneys worse than taking none at all.

Once when she checked her blood sugar at home, the meter pegged at the top of the scale. Her blood sugar had gone off the chart. She was at risk for a stroke.

For several years, Johnson went to the emergency room one to three times a year, not uncommon for uninsured patients, according to the Center for Health Statistics.

An unhealthy cycle

Nearly six years ago, Johnson got a data-entry job at a mortgage-servicing company in Garner with about 10 employees. The owner has looked into providing health insurance for the staff several times. But each time, Johnson says, the rep comes in, looks over the applications of the mostly young and healthy staff, then stops at Johnson's.

"I throw the whole thing off," she says, "because of my age and pre-existing conditions."

One health care reform proposal would help people buy insurance through an "exchange" whose companies could not deny coverage or price it exorbitantly because of pre-existing conditions.

Johnson sees another possible solution: the proliferation of places like Alliance Medical Ministry, a nonprofit that opened in 2003 nearWakeMed in Raleigh to provide affordable primary care to the working poor.

Dr. Tara Lewis, medical director for Alliance, says about 90 percent of the patients who come for treatment have no insurance and no regular doctor, and have been off needed medications so long they have gotten sick enough to require a trip to an emergency room. After treating them, ER staff now send many of their patients to Alliance to try to break that cycle.

Lewis, a small staff of part-time physicians and 250 volunteers work with about 7,500 patients in a renovated church. In addition, Alliance operates an acute-care clinic for same-day visits. Acute care costs $25. Primary-care visits are charged on a sliding scale; most are $15 each.

Alliance doctors can't do everything, and every day Lewis sees patients who need a specialist's care and can't afford it.

"We hear it all the time," Lewis says. "We want to order a test, and the first question is, 'How much is that going to cost?'"

So the cycle begins again, Lewis says.

When patients repeatedly ignore health problems until they have an emergency, their overall health suffers and everyone's costs increase, including those of insured patients who help absorb the hospital costs of those who can't pay.

Still not in the clear

Johnson, the patient, thinks she owes her life to Alliance doctors. Regular visits and counseling on how to manage her diabetes probably averted a stroke or heart attack, she says. And just as important, she says, "Alliance gave me my dignity back."

Lately, though, Johnson has been retaining fluid and her blood pressure has been unstable. She needs a chest X-ray and an electrocardiogram. Another trip to WakeMed, another bill she can't pay.

It's been at least three weeks. She still hasn't made the appointment.